Vibrant Health Membership Interest & Care Needs Questionnaire
Thank you for your interest in becoming a member at Vibrant Health of Colorado. To help us better understand your needs and ensure you are scheduled with the most appropriate provider, please complete the questionnaire below. This allows our team to match you with the right care and set expectations for your experience in our practice. Important: We are not an insurance-based practice. Our providers care for patients through a monthly membership model. Insurance may still be used for services outside of our office (such as labs, imaging, prescriptions, and specialist care), but appointments with our providers are covered through your membership rather than insurance.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What are you hoping to be seen for? Please select all that apply
*
Primary Care
Gynecology/Women's Health
Hormone Replacement Therapy
Weight Loss
Functional Medicine
Which Provider do you want to sign up under?
*
Miranda Minter, MSN, FNP-C (Lone Tree Office)
Jennifer Bienemann, WHNP-BC (Lone Tree Office)
Nicco Long, MSN, FNP-C (Eagle Office)
Melanie Cross, NP-C, AFMC (Eagle Office)
Do you currently have or have you been diagnosed with any of the following?Please select all that apply:
*
Hypothyroidism
Hyperthyroidism
Hashimoto’s thyroiditis
Long COVID
Chronic fatigue
MCAS (Mast Cell Activation Syndrome)
EDS (Ehlers-Danlos Syndrome)
POTS (Postural Orthostatic Tachycardia Syndrome)
Mold or mycotoxin illness
Lyme disease
Irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD)
Chronic GERD / reflux
SIBO (Small Intestinal Bacterial Overgrowth)
Type 1 diabetes
Type 2 diabetes
Cardiovascular disease
Autoimmune disease
None of the above
Back
Next
Autoimmune disease (please specify below)
*
Have you previously worked with a functional medicine provider?
*
Yes
No
What were you being treated for?
*
Is there anything else you would like us to know about your health concerns or goals?
Submit
Should be Empty: